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First Rib Removal And Costoclavicular Junction Decompression In A Patient With Threatened Arteriovenous Hemodialysis Access
Ann C. Gaffey, MD, Jon G. Quatromoni, MD, Julia D. Glaser, MD, Venkat Kalapatapu, MD.
Hospital of the University of Pennslyvania, PHILADELPHIA, PA, USA.

DEMOGRAPHICS: We report a case of a 31-year-old female with sickle cell disease, pulmonary hypertension, and end stage renal disease who presented with aneurysmal degeneration of her left upper extremity AVF. Initial treatment outside of our hospital system involved balloon angioplasty and subsequent secondary venous stenting; however, given failure in resolution of her symptoms a different etiology of aneurysmal degeneration was investigated.
HISTORY: Autologous arteriovenous fistulas (AVFs) are frequently threatened by central venous obstruction. Commonly such venous outflow issues are ascribed to indwelling catheters and neointimal venous remodeling. In a subset of dialysis patients, extrinsic compression of the subclavian vein as it passes through the costoclavicular junction may play a significant role and require evaluation. PLAN: Following a pre-operative venogram that confirmed extrinsic compression of the subclavian stent, we elected to perform a supraclavicular approach to remove the first rib, decompress the costoclavicular junction, and facilitate hemodialysis. At her 5-month follow up, she continues to receive dialysis through her left AVF without aneurysmal degeneration or associated prolonged bleeding times.
DISCUSSION: In this high-risk group of patients with threatened AV access attributed to central venous obstruction, evaluation of the thoracic outlet is paramount. Surgical decompression by means of first rib or clavicular resection should be considered in patients who do not have improvement in their symptoms following initial treatment with endovascular techniques. Overall, the principles of venous thoracic outlet syndrome treatment can be applied and effective for salvage of hemodialysis access.


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